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Alcoholism

Alcoholism
Classification and external resources

"King Alcohol and his Prime Minister" circa 1820
ICD-10 F10..2
ICD-9 303
MedlinePlus alcoholism
MeSH D000437

Alcoholism, also known as alcohol dependence,[1][2] is a disabling addictive disorder. It is characterized by compulsive and uncontrolled consumption of alcohol despite its negative effects on the drinker's health, relationships, and social standing. Like other drug addictions, alcoholism is medically defined as a treatable disease.[3] The term "alcoholism" is a widely used term first coined in 1849 by Magnus Huss, but in medicine the term was replaced by "alcohol abuse" and "alcohol dependence" in the 1980s DSM III.[4] Similarly in 1979 an expert World Health Organisation committee disfavoured the use of "alcoholism" as a diagnostic entity, preferring the category of "alcohol dependence syndrome".[5] In the 19th and early 20th centuries, alcohol dependence was called dipsomania before the term "alcoholism" replaced it.[6]

The biological mechanisms underpinning alcoholism are uncertain, however, risk factors include social environment, stress,[7] mental health, genetic predisposition, age, ethnic group, and sex.[8][9] Long-term alcohol abuse produces physiological changes in the brain such as tolerance and physical dependence. Such brain chemistry changes maintain the alcoholic's compulsive inability to stop drinking and result in alcohol withdrawal syndrome upon discontinuation of alcohol consumption.[10] Alcohol damages almost every organ in the body, including the brain; because of the cumulative toxic effects of chronic alcohol abuse, the alcoholic risks suffering a range of medical and psychiatric disorders.[11] Alcoholism has profound social consequences for alcoholics and the people of their lives.[12][13]

Alcoholism is the cyclic presence of tolerance, withdrawal, and excessive alcohol use; the drinker's inability to control such compulsive drinking, despite awareness of its harm to his or her health, indicate that the person might be an alcoholic.[14] Questionnaire-based screening is a method of detecting harmful drinking patterns, including alcoholism.[15] Alcohol detoxification is conducted to withdraw the alcoholic person from drinking alcohol, usually with cross-tolerance drugs, e.g. benzodiazepines to manage withdrawal symptoms.[16] Post-medical care, such as group therapy, or self-help groups, usually is required to maintain alcoholic abstention.[17][18] Often, alcoholics also are addicted to other drugs, most often benzodiazepines, which might require additional medical treatment.[19] The alcoholic woman is more sensitive to alcohol's deleterious physical, cerebral, and mental effects, and increased social stigma, in relation to a man, for being an alcoholic.[20][21] The World Health Organisation estimates that there are 140 million alcoholics worldwide.[22][23]

Contents

Classification and terminology

Misuse, problem use, abuse, and heavy use refers to improper use of alcohol which may cause physical, social, or moral harm to the drinker.[24] Moderate use is defined by The Dietary Guidelines for Americans as no more than two alcoholic beverages per day for men and no more than one alcoholic beverage per day for women.[25]

The term "alcoholism" is commonly used, but poorly defined. The WHO defines alcoholism as "a term of long-standing use and variable meaning", and use of the term was disfavored by a 1979 WHO Expert Committee. The Big Book (from Alcoholics Anonymous) states that once a person is an alcoholic, he always is an alcoholic, but does not define what is meant by the term "alcoholic" in this context. In 1960, Bill W. said:

We have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease. Instead there are many separate heart ailments, or combinations of them. It is something like that with alcoholism. Therefore we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore we always called it an illness, or a malady -- a far safer term for us to use.[26]

In professional and research contexts, the term "alcoholism" sometimes encompasses both alcohol abuse and alcohol dependence.[27] and sometimes is considered equivalent to alcohol dependence.

In psychology and psychiatry, the DSM is the most common global standard, while in medicine, the standard is ICD. The terms they recommend are similar but not identical:

Organization Preferred term(s) Definition
APA's DSM-IV "alcohol abuse" and "alcohol dependence"
  • alcohol abuse = repeated use despite recurrent adverse consequences.[28]
  • alcohol dependence = alcohol abuse combined with tolerance, withdrawal, and an uncontrollable drive to drink.[28]

The term "alcoholism" was split into "alcohol abuse" and "alcohol dependence" in 1980's DSM-III, and in 1987's DSM-III-R behavioral symptoms were moved from "abuse" to "dependence".[4] It has been suggested that DSM-V merge alcohol abuse and alcohol dependence into a single new entry,[29] named "alcohol-use disorder".[30]

WHO's ICD-10 "alcohol harmful use" and "alcohol dependence syndrome" Definitions are similar to that of the DSM-IV. The World Health Organisation uses the term alcohol dependence syndrome rather than alcoholism.[5] The concept of "harmful use" (as opposed to "abuse") was introduced in 1992's ICD-10 to minimize underreporting of damage in the absence of dependence.[4] The term "alcoholism" was removed from ICD between ICD-8/ICDA-8 and ICD-9.[31]

Despite the imprecision inherent in the term, there have been attempts to define how the word "alcoholism" should be interpreted when encountered. In 1992, it was defined by the NCADD and ASAM as "a primary, chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking."[32] MeSH has had an entry for "alcoholism" since 1999, and references the 1992 definition.[33]

Etymology

1904 advertisement describing alcoholism as a disease.

Historically the name dipsomania was coined by German physician Dr. C. W. Hufeland in 1819 before it was superseded by alcoholism.[34][35] The term "alcoholism" was first used in 1849 by the Swedish physician Magnus Huss to describe the systematic adverse effects of alcohol.[36]

AA describes alcoholism as an illness that involves a physical allergy[37]:p.28 and a mental obsession.[37]:p.23[38] Note that the definition of "allergy" used in this context is not the same as used in modern medicine.[39] The doctor and addiction specialist Dr. William D. Silkworth M.D. writes on behalf of AA that "Alcoholics suffer from a "(physical) craving beyond mental control".[37]:XXVI

A 1960 study by E. Morton Jellinek is considered the foundation of the modern disease theory of alcoholism.[40] Jellinek's definition restricted the use of the word "alcoholism" to those showing a particular natural history. The modern medical definition of alcoholism has been revised numerous times since then. The American Medical Association currently uses the word alcoholism to refer to a particular chronic primary disease.[41]

A minority opinion within the field, notably advocated by Herbert Fingarette and Stanton Peele, argue against the existence of alcoholism as a disease. Critics of the disease model tend to use the term "heavy drinking" when discussing the negative effects of alcohol consumption.

Signs and symptoms

Symptoms of long term alcohol misuse

Alcoholism is characterised by an increased tolerance of and physical dependence on alcohol, affecting an individual's ability to control alcohol consumption safely. These characteristics are believed to play a role in impeding an alcoholic's ability to stop drinking.[10] Alcoholism can have adverse effects on mental health, causing psychiatric disorders to develop and an increased risk of suicide.[42][43]

Physical symptoms

Some of the possible long-term effects of ethanol an individual may develop. Additionally, in pregnant women, alcohol can cause fetal alcohol syndrome.

Long term alcohol abuse can cause a number of physical symptoms, including cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, nutritional deficiencies, and sexual dysfunction, and can eventually be fatal. Other physical effects include an increased risk of developing cardiovascular disease, malabsorption, alcoholic liver disease, and cancer. Damage to the central nervous system and peripheral nervous system can occur from sustained alcohol consumption.[44][45]

Women develop long-term complications of alcohol dependence more rapidly than do men. Additionally, women have a higher mortality rate from alcoholism than men.[20] Examples of long term complications include brain, heart, and liver damage[21] and an increased risk of breast cancer. Additionally, heavy drinking over time has been found to have a negative effect on reproductive functioning in women. This results in reproductive dysfunction such as anovulation, decreased ovarian mass, problems or irregularity of the menstrual cycle, and early menopause.[20] Alcoholic ketoacidosis can occur in individuals who chronically abuse alcohol and have a recent history of binge drinking.[46]

Psychiatric symptoms

Long term misuse of alcohol can cause a wide range of mental health problems. Severe cognitive problems are not uncommon; approximately 10 percent of all dementia cases are related to alcohol consumption, making it the second leading cause of dementia.[47] Excessive alcohol use causes damage to brain function, and psychological health can be increasingly affected over time.[48]

Psychiatric disorders are common in alcoholics, with as many as 25 percent suffering severe psychiatric disturbances. The most prevalent psychiatric symptoms are anxiety and depression disorders. Psychiatric symptoms usually initially worsen during alcohol withdrawal, but typically improve or disappear with continued abstinence.[49] Psychosis, confusion, and organic brain syndrome may be caused by alcohol misuse, which can lead to a misdiagnosis such as schizophrenia.[50] Panic disorder can develop or worsen as a direct result of long term alcohol misuse.[51][52]

The co-occurrence of major depressive disorder and alcoholism is well documented.[53][54][55] Among those with comorbid occurrences, a distinction is commonly made between depressive episodes that remit with alcohol abstinence ("substance-induced"), and depressive episodes that are primary and do not remit with abstinence ("independent" episodes).[56][57][58] Additional use of other drugs may increase the risk of depression.[59]

Psychiatric disorders differ depending on gender. Women who have alcohol-use disorders often have a co-occurring psychiatric diagnosis such as major depression, anxiety, panic disorder, bulimia, post-traumatic stress disorder (PTSD), or borderline personality disorder. Men with alcohol-use disorders more often have a co-occurring diagnosis of narcissistic or antisocial personality disorder, bipolar disorder, schizophrenia, impulse disorders or attention deficit/hyperactivity disorder.[60] Women with alcoholism are more likely to have a history of physical or sexual assault, abuse and domestic violence than those in the general population,[60] which can lead to higher instances of psychiatric disorders and greater dependence on alcohol.

Social effects

The social problems arising from alcoholism are serious, caused by the pathological changes in the brain and the intoxicating effects of alcohol.[47][61] Alcohol abuse is associated with an increased risk of committing criminal offences, including child abuse, domestic violence, rape, burglary and assault.[62] Alcoholism is associated with loss of employment,[63] which can lead to financial problems. Drinking at inappropriate times, and behavior caused by reduced judgment, can lead to legal consequences, such as criminal charges for drunk driving[13] or public disorder, or civil penalties for tortious behavior, and may lead to a criminal sentence.

An alcoholic's behavior and mental impairment, while drunk, can profoundly impact those surrounding them and lead to isolation from family and friends. This isolation can lead to marital conflict and divorce, or contribute to domestic violence. Alcoholism can also lead to child neglect, with subsequent lasting damage to the emotional development of the alcoholic's children.[12]

Alcohol withdrawal

As with similar substances with a sedative-hypnotic mechanism, such as barbiturates and benzodiazepines, withdrawal from alcohol dependence can be fatal if it is not properly managed.[61][64] Alcohol's primary effect is the increase in stimulation of the GABAA receptor, promoting central nervous system depression. With repeated heavy consumption of alcohol, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence. When alcohol consumption is stopped too abruptly, the person's nervous system suffers from uncontrolled synapse firing. This can result in symptoms that include anxiety, life threatening seizures, delirium tremens, hallucinations, shakes and possible heart failure.[65][66] Other neurotransmitter systems are also involved, especially dopamine and NMDA.[10][67]

Acute withdrawal symptoms tend to subside after one to three weeks. Less severe symptoms (e.g. insomnia and anxiety, anhedonia) may continue as part of a post withdrawal syndrome gradually improving with abstinence for a year or more.[68][69][70] Withdrawal symptoms begin to subside as the body and central nervous system restore alcohol tolerance and GABA functioning towards normal.[71][72]

Causes

A complex mixture of genetic and environmental factors influence the risk of the development of alcoholism.[73] Genes which influence the metabolism of alcohol also influence the risk of alcoholism, and may be indicated by a family history of alcoholism.[74] One paper has found that alcohol use at an early age may influence the expression of genes which increase the risk of alcohol dependence.[75] Individuals who have a genetic disposition to alcoholism are also more likely to begin drinking at an earlier age than average.[76] Also, a younger age of onset of drinking is associated with an increased risk of the development of alcoholism,[76] and about 40 percent of alcoholics will drink excessively by their late adolescence. It is not entirely clear whether this association is causal, and some researchers have been known to disagree with this view.[77]

Severe childhood trauma is also associated with an general increase in the risk of drug dependency.[73] Lack of peer and family support is associated with a increased risk of alcoholism developing.[73] Genetics and adolescence are associated with an increased sensitivity to the neurotoxic effects of chronic alcohol abuse. Cortical degeneration due to the neurotoxic effects increases impulsive behaviour, which may contribute to the development, persistence and severity of alcohol use disorders. There is evidence that with abstinence, there is a reversal of at least some of the alcohol induced central nervous system damage.[78]

Genetic variation

Genetic differences exist between different racial groups which affect the risk of developing alcohol dependence. For example, there are differences between African, East Asian and Indo-racial groups in how they metabolize alcohol. These genetic factors are believed to, in part, explain the differing rates of alcohol dependence among racial groups.[79][80] The alcohol dehydrogenase allele ADH1 B*3 causes a more rapid metabolism of alcohol. The allele ADH1 B*3 is only found in those of African descent and certain Native American tribes. African and native Americans with this allele have a reduced risk of developing alcoholism.[81] Native Americans however, have a significantly higher rate of alcoholism than average; it is unclear why this is the case.[82] Other risk factors such as cultural environmental effects e.g. trauma have been proposed to explain the higher rates of alcoholism among Native Americans compared to alcoholism levels in caucasians.[83][84]

Pathophysiology

Alcohol's primary effect is the increase in stimulation of the GABAA receptor, promoting central nervous system depression. With repeated heavy consumption of alcohol, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence.[65] The amount of alcohol that can be biologically processed and its effects differ between sexes. Equal dosages of alcohol consumed by men and women generally result in women having higher blood alcohol concentrations (BACs).[60] This can be attributed to many reasons, the main being that women have less body water than men. A given amount of alcohol, therefore becomes more highly concentrated in a woman's body. A given amount of alcohol causes greater intoxication for women due to different hormone release compared to men.[21]

Diagnosis

Social barriers

Attitudes and social stereotypes can create barriers to the detection and treatment of alcohol abuse. This is more of a barrier for women than men. Fear of stigmatization may lead women to deny that they are suffering from a medical condition, to hide their drinking, and to drink alone. This pattern, in turn, leads family, physicians, and others to be less likely to suspect that a woman they know is an alcoholic.[20] In contrast, reduced fear of stigma may lead men to admit that they are suffering from a medical condition, to publicly display their drinking, and to drink in groups. This pattern, in turn, leads family, physicians, and others to be more likely to suspect that a man they know is an alcoholic.[60]

Screening

Several tools may be used to detect a loss of control of alcohol use. These tools are mostly self reports in questionnaire form. Another common theme is a score or tally that sums up the general severity of alcohol use.[15]

The CAGE questionnaire, named for its four questions, is one such example that may be used to screen patients quickly in a doctor's office.

Two "yes" responses indicate that the respondent should be investigated further. The questionnaire asks the following questions:

  1. Have you ever felt you needed to Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt Guilty about drinking?
  4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?[85][86]
The CAGE questionnaire has demonstrated a high effectiveness in detecting alcohol related problems; however, it has limitations in people with less severe alcohol related problems, white women and college students.[87]

Other tests are sometimes used for the detection of alcohol dependence, such as the Alcohol Dependence Data Questionnaire, which is a more sensitive diagnostic test than the CAGE questionnaire. It helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol use.[88] The Michigan Alcohol Screening Test (MAST) is a screening tool for alcoholism widely used by courts to determine the appropriate sentencing for people convicted of alcohol-related offenses,[89] driving under the influence being the most common. The Alcohol Use Disorders Identification Test (AUDIT), a screening questionnaire developed by the World Health Organization, is unique in that it has been validated in six countries and is used internationally. Like the CAGE questionnaire, it uses a simple set of questions – a high score earning a deeper investigation.[90] The Paddington Alcohol Test (PAT) was designed to screen for alcohol related problems amongst those attending Accident and Emergency departments. It concords well with the AUDIT questionnaire but is administered in a fifth of the time.[91]

Genetic predisposition testing

Psychiatric geneticists John I. Nurnberger, Jr., and Laura Jean Bierut suggest that alcoholism does not have a single cause—including genetic—but that genes do play an important role "by affecting processes in the body and brain that interact with one another and with an individual's life experiences to produce protection or susceptibility". They also report that fewer than a dozen alcoholism-related genes have been identified, but that more likely await discovery.[92]

At least one genetic test exists for an allele that is correlated to alcoholism and opiate addiction.[93] Human dopamine receptor genes have a detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess the A1 allele (variation) of this polymorphism have a small but significant tendency towards addiction to opiates and endorphin-releasing drugs like alcohol.[94] Although this allele is slightly more common in alcoholics and opiate addicts, it is not by itself an adequate predictor of alcoholism, and some researchers argue that evidence for DRD2 is contradictory.[92]

DSM diagnosis

The DSM-IV diagnosis of alcohol dependence represents one approach to the definition of alcoholism. In part this is to assist in the development of research protocols in which findings can be compared to one another. According to the DSM-IV, an alcohol dependence diagnosis is:[14]

... maladaptive alcohol use with clinically significant impairment as manifested by at least three of the following within any one-year period: tolerance; withdrawal; taken in greater amounts or over longer time course than intended; desire or unsuccessful attempts to cut down or control use; great deal of time spent obtaining, using, or recovering from use; social, occupational, or recreational activities given up or reduced; continued use despite knowledge of physical or psychological sequelae.

Urine and blood tests

There are reliable tests for the actual use of alcohol, one common test being that of blood alcohol content (BAC).[95] These tests do not differentiate alcoholics from non-alcoholics; however, long-term heavy drinking does have a few recognizable effects on the body, including:[96]

However, none of these blood tests for biological markers are as sensitive as screening questionnaires.

Prevention

The World Health Organization, the European Union and other regional bodies, national governments and parliaments have formed alcohol policies in order to reduce the harm of alcoholism.[97][98] Targeting adolescents and young adults is regarded as an important step to reduce the harm of alcohol abuse. Increasing the age at which licit drugs of abuse such as alcohol can be purchased, the banning or restricting advertising of alcohol has been recommended as additional ways of reducing the harm of alcohol dependence and abuse. Credible, evidence based educational campaigns in the mass media about the consequences of alcohol abuse have been recommended. Guidelines for parents to prevent alcohol abuse amongst adolescents, and for helping young people with mental health problems have also been suggested.[99]

Management

Treatments are varied because there are multiple perspectives of alcoholism. Those who approach alcoholism as a medical condition or disease recommend differing treatments than, for instance, those who approach the condition as one of social choice. Most treatments focus on helping people discontinue their alcohol intake, followed up with life training and/or social support in order to help them resist a return to alcohol use. Since alcoholism involves multiple factors which encourage a person to continue drinking, they must all be addressed in order to successfully prevent a relapse. An example of this kind of treatment is detoxification followed by a combination of supportive therapy, attendance at self-help groups, and ongoing development of coping mechanisms. The treatment community for alcoholism typically supports an abstinence-based zero tolerance approach; however, there are some who promote a harm-reduction approach as well.[100]

Detoxification

Alcohol detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking coupled with the substitution of drugs, such as benzodiazepines, that have similar effects to prevent alcohol withdrawal. Individuals who are only at risk of mild to moderate withdrawal symptoms can be detoxified as outpatients. Individuals at risk of a severe withdrawal syndrome as well as those who have significant or acute comorbid conditions are generally treated as inpatients. Detoxification does not actually treat alcoholism, and it is necessary to follow-up detoxification with an appropriate treatment program for alcohol dependence or abuse in order to reduce the risk of relapse.[16]

Group therapy and psychotherapy

A regional service center for Alcoholics Anonymous.

Various forms of group therapy or psychotherapy can be used to deal with underlying psychological issues that are related to alcohol addiction, as well as provide relapse prevention skills. The mutual-help group-counseling approach is one of the most common ways of helping alcoholics maintain sobriety.[17][18] Alcoholics Anonymous was one of the first organizations formed to provide mutual, nonprofessional counseling, and it is still the largest. Others include LifeRing Secular Recovery, SMART Recovery, and Women For Sobriety.

Rationing and moderation

Rationing and moderation programs such as Moderation Management and DrinkWise do not mandate complete abstinence. While most alcoholics are unable to limit their drinking in this way, some return to moderate drinking. A 2002 U.S. study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) showed that 17.7 percent of individuals diagnosed as alcohol dependent more than one year prior returned to low-risk drinking. This group, however, showed fewer initial symptoms of dependency.[101] A follow-up study, using the same subjects that were judged to be in remission in 2001–2002, examined the rates of return to problem drinking in 2004–2005. The study found abstinence from alcohol was the most stable form of remission for recovering alcoholics.[102] A long-term (60 year) follow-up of two groups of alcoholic men concluded that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence."[103]

Medications

A variety of medications may be prescribed as part of treatment for alcoholism.

Medications currently in use

  • Antabuse (disulfiram) prevents the elimination of acetaldehyde, a chemical the body produces when breaking down ethanol. Acetaldehyde itself is the cause of many hangover symptoms from alcohol use. The overall effect is severe discomfort when alcohol is ingested: an extremely fast-acting and long-lasting uncomfortable hangover. This discourages an alcoholic from drinking in significant amounts while they take the medicine. A recent 9-year study found that incorporation of supervised disulfiram and the related compound carbamide into a comprehensive treatment program resulted in an abstinence rate of over 50 percent.[104]
  • Naltrexone is a competitive antagonist for opioid receptors, effectively blocking the effects of endorphins and opiates. Naltrexone is used to decrease cravings for alcohol and encourage abstinence. Alcohol causes the body to release endorphins, which in turn release dopamine and activate the reward pathways; hence when naltrexone is in the body there is a reduction in the pleasurable effects from consuming alcohol.[106] Naltrexone is also used in an alcoholism treatment method called the Sinclair Method, which treats patients through a combination of Naltrexone and continued drinking.[107]

Experimental medications

  • Topamax (topiramate), a derivative of the naturally occurring sugar monosaccharide D-fructose, has been found effective in helping alcoholics quit or cut back on the amount they drink. Evidence suggests that topiramate antagonizes excitatory glutamate receptors, inhibits dopamine release, and enhances inhibitory gamma-aminobutyric acid function. A 2008 review of the effectiveness of topiramate concluded that the results of published trials are promising, however as of 2008, data was insufficient to support using topiramate in conjunction with brief weekly compliance counseling as a first-line agent for alcohol dependence.[109] A 2010 review found that topiramate may be superior to existing alcohol pharmacotherapeutic options. Topiramate effectively reduces craving and alcohol withdrawal severity as well as improving quality-of-life-ratings.[110]

Medications which may worsen outcome

  • Benzodiazepines, whilst useful in the management of acute alcohol withdrawal, if used long-term cause a worse outcome in alcoholism. Alcoholics on chronic benzodiazepines have a lower rate of achieving abstinence from alcohol than those not taking benzodiazepines. This class of drugs are commonly prescribed to alcoholics for insomnia or anxiety management.[111] Initiating prescriptions of benzodiazepines or sedative-hypnotics in individuals in recovery has a high rate of relapse with one author reporting more than a quarter of people relapsed after being prescribed sedative-hypnotics. Patients often mistakenly think that they are sober despite continuing to take benzodiazepines. Those who are long-term users of benzodiazepines should not be withdrawn rapidly, as severe anxiety and panic may develop, which are known risk factors for relapse into alcohol abuse. Taper regimes of 6–12 months have been found to be the most successful, with reduced intensity of withdrawal.[112][113]

Dual addictions

Alcoholics may also require treatment for other psychotropic drug addictions. The most common dual addiction in alcohol dependence is a benzodiazepine dependence, with studies showing 10–20 percent of alcohol-dependent individuals had problems of dependence and/or misuse problems of benzodiazepines. Benzodiazepines increase cravings for alcohol and the volume of alcohol consumed by problem drinkers.[114] Benzodiazepine dependency requires careful reduction in dosage to avoid benzodiazepine withdrawal syndrome and other health consequences.

Dependence on other sedative hypnotics such as zolpidem and zopiclone as well as opiates and illegal drugs is common in alcoholics. Alcohol itself is a sedative-hypnotic and is cross-tolerant with other sedative-hypnotics such as barbiturates, benzodiazepines and nonbenzodiazepines. Dependence upon and withdrawal from sedative hypnotics can be medically severe and, as with alcohol withdrawal, there is a risk of psychosis or seizures if not managed properly.[19]

Epidemiology

Disability-adjusted life year for alcohol use disorders per 100,000 inhabitants in 2002.
     no data      less than 50      50–150      150–250      250–350      350–450      450–550      550–650      650–750      750–850      850–950      950–1050      more than 1050
Total recorded yearly alcohol per capita consumption (15+), in litres of pure alcohol[115]

Substance use disorders are a major public health problem facing many countries. "The most common substance of abuse/dependence in patients presenting for treatment is alcohol."[100] In the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8 million in 2001.[116] About 12% of American adults have had an alcohol dependence problem at some time in their life.[117] The World Health Organization estimates that about 140 million people throughout the world suffer from alcohol dependence.[22][23] In the United States and western Europe 10 to 20 percent of men and 5 to 10 percent of women at some point in their lives will meet criteria for alcoholism.[118]

Within the medical and scientific communities, there is broad consensus regarding alcoholism as a disease state. For example, the American Medical Association considers alcohol a drug and states that "drug addiction is a chronic, relapsing brain disease characterized by compulsive drug seeking and use despite often devastating consequences. It results from a complex interplay of biological vulnerability, environmental exposure, and developmental factors (e.g., stage of brain maturity)."[41]

Alcoholism has a higher prevalence among men, though in recent decades, the proportion of female alcoholics has increased.[21] Current evidence indicates that in both men and women, alcoholism is 50–60 percent genetically determined, leaving 40–50 percent for environmental influences.[119] Most alcoholics develop alcoholism during adolescence or young adulthood.[73]

Prognosis

A 2002 study by the National Institute on Alcohol Abuse and Alcoholism surveyed a group of 4,422 adults meeting the criteria for alcohol dependence and found that after one year, some met the authors' criteria for low-risk drinking, even though only 25.5 percent of the group received any treatment, with the breakdown as follows: 25 percent were found to be still dependent, 27.3 percent were in partial remission (some symptoms persist), 11.8 percent asymptomatic drinkers (consumption increases chances of relapse) and 35.9 percent were fully recovered — made up of 17.7 percent low-risk drinkers plus 18.2 percent abstainers.[120]

In contrast, however, the results of a long term (60 year) follow-up of two groups of alcoholic men by George Vaillant at Harvard Medical School indicated that "return to controlled drinking rarely persisted for much more than a decade without relapse or evolution into abstinence."[121] Vaillant also noted that "return-to-controlled drinking, as reported in short-term studies, is often a mirage."

The most common cause of death in alcoholics is from cardiovascular complications.[122] There is a high rate of suicide in chronic alcoholics, which increases the longer a person drinks. This is believed to be due to alcohol causing physiological distortion of brain chemistry, as well as social isolation. Suicide is also very common in adolescent alcohol abusers, with 25 percent of suicides in adolescents being related to alcohol abuse.[123] Approximately 18 percent of alcoholics commit suicide,[43] and research has found that over 50 percent of all suicides are associated with alcohol or drug dependence. The figure is higher for adolescents, with alcohol or drug misuse playing a role in up to 70 percent of suicides.[124]

History

Alcohol has a long history of use and misuse throughout recorded human history. Biblical, Egyptian and Babylonian sources record history of abuse and dependence on alcohol. In some ancient cultures alcohol was worshiped and others its abuse was condemned. Excessive alcohol misuse and drunkenness were recognised as causing problems thousand of years ago. However, the defining of habitual drunkenness as it was then known as and its adverse consequences were not well established medically until the 1700s. In 1647 a Greek monk[who?] was the first to document that chronic alcohol misuse was associated with toxicity to the nervous system and body which resulted in a range of medical disorders such as seizures, paralysis and internal bleeding. In 1920 the effects of alcohol abuse and chronic drunkenness led to the failed prohibition of alcohol being considered and eventually enforced briefly in America. In 2005 the cost of alcohol dependence and abuse was estimated to cost the USA economy approximately 220 billion dollars per year, more than cancer and obesity.[125]

Society and culture

The various health problems associated with long-term alcohol consumption are generally perceived as detrimental to society, for example, money due to lost labor-hours, medical costs, and secondary treatment costs. Alcohol use is a major contributing factor for head injuries, motor vehicle accidents, violence, and assaults. Beyond money, there are also significant social costs to both the alcoholic and their family and friends.[61] For instance, alcohol consumption by a pregnant woman can lead to fetal alcohol syndrome,[126] an incurable and damaging condition.[127]

Estimates of the economic costs of alcohol abuse, collected by the World Health Organization, vary from one to six percent of a country's GDP.[128] One Australian estimate pegged alcohol's social costs at 24 percent of all drug abuse costs; a similar Canadian study concluded alcohol's share was 41 percent.[129] One study quantified the cost to the UK of all forms of alcohol misuse in 2001 as â£18.5–20 billion.[116][130]

Stereotypes of alcoholics are often found in fiction and popular culture. The 'town drunk' is a stock character in Western popular culture. Stereotypes of drunkenness may be based on racism or xenophobia, as in the depiction of the Irish as heavy drinkers.[131] Studies by social psychologists Stivers and Greeley attempt to document the perceived prevalence of high alcohol consumption amongst the Irish in America.[132]

See also

References

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  2. ^ Department of Health and Human Services. "Alcohol Dependence (Alcoholism)" (PDF). National Institutes of Health. http://www.nih.gov/about/researchresultsforthepublic/AlcoholDependenceAlcoholism.pdf. 
  3. ^ American Medical Association. "DEFINITIONS" (PDF). USA: AMA. http://www.ama-assn.org/ama1/pub/upload/mm/388/alcoholism_treatable.pdf. 
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